Get Jps Health Network Verification Of Assistance And Residency For Jps Connection Program

The JPS Health Network Verification of Assistance and Residency for the JPS Connection Program is an essential form that supports individuals who receive assistance from others. This guide provides clear, step-by-step instructions for completing the form online to ensure accuracy and compliance.

Follow the steps to effectively complete the form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. In the first section, enter the name of the person providing assistance in the designated space. This will confirm the identity of the individual who is supporting the applicant.
3. Next, input the applicant’s full name in the provided field. This ensures clarity regarding whom the assistance pertains to.
4. Provide the patient’s medical record number (MR#) and/or social security number in the respective fields to identify the applicant uniquely.
5. Fill in the applicant's complete address, including the city and zip code, to confirm the residency information.
6. Select 'Yes' or 'No' to indicate if you provide financial assistance to the applicant. If applicable, confirm whether this person is listed as a dependent on your most recent filed income tax return.
7. Indicate if the applicant has a job, and if yes, provide their employer's name for verification of employment.
8. If the applicant has another income source, specify the details in the corresponding field.
9. List the types of assistance provided to the applicant (food, personal items, cash/check, transportation, or other) and specify the amount of cash/check assistance if applicable.
10. Answer whether you pay rent or other bills for the applicant, detailing how much and how frequently.
11. Confirm that the applicant resides at your Tarrant County residence and specify any rent or utility contributions made by the applicant.
12. State how long the applicant has lived at your residence and indicate if they have another residence, providing details if necessary.
13. Attach required documentation, including a picture identification and proof of residence, as specified.
14. Complete the relationship to the patient section, and ensure your information is accurate.
15. Certify that all information is true and correct by signing the form, providing your address, phone number, and the date signed.
16. Finally, the form must be notarized. Ensure you visit a notary public to complete this requirement.
17. Upon completion, save changes, download, print, or share the form as needed.

Complete the JPS Health Network Verification of Assistance and Residency for JPS Connection Program form online for efficient processing.